The Relationship Between CT Imaging Index And The Effect Of Sacral Canal Injection On The Patients With Lumbar Disc Protrusion

1 ObjectiveExplore the relationship between CT imaging index and the effect of sacral canal injection on the patients with Lumbar Disc Protrusion. Discovery The Clinical Value of the sacral canal injection.Providing an objective basis to predict the clinical curative effect of sacral tube injection.2 General Information2.1 Cases sourceFrom March 2009 to March 2010,we selected 130 cases with single segment prolapse of lumbar intervertebral disc patients.All of them accepted sacral tube injection were from Nanfang Hospital and Guangzhou Hospital of Integrated Tranditional and Western Medicine.2.2 Object of study130 cases with single segment prolapse of lumbar intervertebral disc patients, including 70 males and 60 females,26～65 years old. The duration of illness was from 0.2-36 monthes.34 patients with Lumbar disc herniation between L3 and L4; 57 patients with Lumbar disc herniation between L4 and L5; 49 patients with Lumbar disc herniation between L5 and S1.2.3 The Diagnosis standard of Lumbar disc herniation:1) Lumbago, leg pain, witch is typical lumbosacral nerve root distribution area of pain, often characterized by lower limb pain heavier than lumbago;2) According to the nerve distribution area, arised anytwo of the four types of neurological dysfunction:muscle atrophy, muscle abate, sensory abnormalities and reflection change;3) Nerve root tension test whether straight legs raise test or strands of neural force test are all positive;4) Radiographic examination:including X-ray, CT examination signs with lumbar intervertebral disc.2.4 Inclusion criteria:refer to curative standard in 1994, witch was released by the state administration of traditional Chinese medicine diagnosis TCM symptoms.1) Lumbago and lower limb pain, restricted movement;2) Straight-leg raising test and strengthen test is positive;3) CT or MRI diagnosed as lumbar intervertebral disc or surfaces, who without stenosis person;4) CT imaging showed single segment of lumbar nucleus pulposus surfaces or outstanding patients.5) All the patients received informed consent2.5 Exclusion standard1) Patients with severe mental illness or organic disease; 2) Lumbar olisthe, lumbar vertebral fracture of compressibility leads to low back pain;3) Low back pain because of tumour, tuberculosis, etc of causes;4) The patients who accept other treating, or this observation within two weeks before the start of the test; The patient of hormone allergy.5)Pregnant women, or who younger than 20 years old or older than 65 patients.6)The patients voluntarily signed with informed consent.2.6 Measuring equipment of CT signalsTo scan L3-L4,L4-L5,L5-S1 vertebrals with Lightspeed 16 layer spiral CT scanner of GE company.The thickness of scan is 3mm, the layer spacing of scan is 2mm.To complete the measurement of the image data in the computer with the help of the PASC system of the image center in NanFang hospital.2.7 CT evaluation index (direct imaging outcome and CT measurement index)2.7.1 CT direct imaging outcome:1) herniated form:uplift type:protrusions well circumscribed, with arc with disc overall continuous outstanding, smooth edges, density, uniformity, protrusions lighter, and shadow often disc close to or below, nerve root scabbard clear, can distinguish with protrusions shadow, y ellow ligament and small joint no secondary change. Ruptured lumbar disc pro trusion:protrusions often submit hills or ground graphics, margin irregular, her nia nucleus pulposus in the shadow can see, sometimes several plane with dur al or nerve root shadow mix together, it is difficult to distinguish; Seqestration: protrusions highly rules, can show cauliflower shape or island shape, some pa rt of calcification.2) anteroposterior axes level There are 3 level in the anterop osterior axes. The intervertebral discs level is 1 level.The upper tier of interver tebral discs is from the inferior thyroid notch of upper vertebral body to the u pper bound of intervertebral disc which we called 2 level. The underlayer of i ntervertebral discs is from the lower bound of intervertebral disc to the inferio r thyroid notch of lower vertebral body which we called 3 level.horizontal pos ition region There are 4 regions behind the posterior border of the vertebral b ody. To divide 3 equation between two pedicles of vertebral arch,the middle e quation is called 1 region,the left or right one called 2 region.3 region is from exterior to interior of pedicle of vertebral arch.4 region is Outside the lateral pedicle of vertebral arch.2.7.2 CT accurate measurement:(1)The measurement of the prominent nucleus' density:, tracing conditions of CT value is 120 kV,130 mA, time 2S. Adopt overlapping scanning technology, continuously scanned, which means thick layer of 3mm and interlamellar spacin of 2mm. Scanning frame and vertebral asked gap were parallel. Measure CT value, through scanning the most clear plane of LDH.We selected three points in the nucleus pulposus center and the sides and repeatedly measured three times, then calculating average. The normal situation is 50-100Hu. If CT value is higher than 100,it means the tissue has been ossification. (2)Sagittal index:the rate of the biggest sagittal diameter of the protrusions to the biggest sagittal diameter of the spinal canal in the sa-me plane.That can be used to describe the size of protrusions.(3)The compressed degree of the nerve root:We made a straight line which was perpendicular to the median line of the canalis vertebralis.The straight line join protrusions and zygapophysial joint respectively with D and E point.The rate of CE and DE could be used to describe the compressed degree of nerve roots.3 Research method3.1 Drug compatibility The 30ml of mixture was composed with 1mlof Prednisolone Acetate in jection,20ml of Sodium Chloride Injection(0.9%),4ml of Mecobalamin for I njection (by Eisai:1ml:0.5mg) and 5ml Lidocaine(2%).3.2 The operating method of sacral canal injectionThe doctor Keep the patients prone position,put Soft pillow down their p elvic, and keep their heads low 15～20°. After the normal disinfections recep tion., pave the ophthalmic surgical drape.Find The sacral hiatus which is about 1cm away from the top of coccyx.First, did the local anesthesia With lidocai ne (2%).Secend,the doctor make the sacral canal puncture with nine needles by 45-degree.If got the vacant feeling and pumped without blood or cerebrospi nal fluid flow,that prove successful. Try to push 2ml basic saline.If without re sistance,we can Injected the configuration solution. The patient feel sour bloate d and heat on the lumbar,someone feel numb of the lower. After the completi on of the injection, pull out the needles and stick sterile cotton. Instruct client to press the original position about 10 minutes, and then prone to supine 20 minutes. Observation not illfeeling can. Observed whether the patients have ad verse reactions or not.3.3 NoteComply with strict aseptic manipulation and avoid into needle rudely. We should observe whether we can inject successfully, because hiatus sacralis ma y be the variable. Watching the vital signs,we should inject slowly. If appearin g slight giddy, the patients can got better when we stop injecting. The heavy patients should be pulled out.The patients had better take a rest for 3 to 6 mo uths after recovery, and avoid sedentary and hard physical labor to prevent rec urrence. 4 Observation method4.1 Observation cycleAll the treatment will be finished in four weeks,and the Patients will be t reated 1 times a week.we'll stop watching, If patientsrecovered in four weeks.4.2 Observe index and evaluation standardRefer to JOA low back pain score, total score is twenty-nine. rate of the im-proved=[(postoperative scores—preoperative score)/(29—preoperative score)]×100%. The result judgement:excellent(RIS≥75%), good(50%≤RIS<74%), fair(25%≤RIS<49%), poor(0≤RIS<24%).5 Observe index and evaluation standardAll data was analyzed by the statistical software SPSS 13.0. The relationship between CT imaging directly observed index and the effect of sacral canal injection on the patients with Lumbar Disc Protrusion was analyzed with Ridit; The relationship between the measured value of the nucleus pulposus by CT and the effect of sacral canal injection on the patients with LDH was analyzed with multiple regression analysis.6 Results6.1 The relationship between CT imaging directly observed index and the effect of sacral canal injection on the patients with LDH6.1.1 Directly observed group:①According to the shape of the hemiated discs organism,the patients were divided into there group:Uplift type, Ruptured lumbar disc protrusion, Seqest ration, each with 67,41,22 patients respectively.②According to the shape of t he hemiated discs organism, the patients were divided into four group:1 secti on,2 section,3 section, each with 41,26,26,14 patients respectively.③Accordin g to Coronary position of hemiated discs organism, the patients were divided i nto three fields:a,b,c, each with 48,44,28 patients respectively. The differences between patients from each group were not statistically significant (P> 0.05) i n the gender, age, duration, etc.6.1.2 The relationship between CT imaging directly observed index and the effect of sacral canal injection on the patients with LDHAfter a cycle treatment, the difference between groups:④There were significant differences of the curative effect between three groups:The 95% confidence interval of the Ridit value of the Bulge was from 0.301 to 0.400. Compared with ruptured and seqestrative LDH, The 95% confidence interval had no overlap.So there were significant difference between the clinical efficacy of the Bulge group and the others. In addition, the Ridit value of the Bulge was below the Ridit value of the standard group.When we analyzed the data, the Ridit value was arranged increasing from optimal to poor,so the clinical efficacy of the patients from the Bulge group was the best,compared with the others.And there were less overlap between the 95% confidence interval of the Ridit value of ruptured LDH with that of the sequestration,so we can get the result that the effects of both of them are significantly different,and the Ridit value of the patients from the ruptured LDH group was less than that from the sequestration group,so the clinical efficacy of the patients from the ruptured LDH group was better.②Compare the curative effect of the herniated level groups:The 95% confidence interval of the Ridit value of 1 region overlayed mostly with that of 2 region.So their effects weren't significantly different(P>0.05). The 95% confidence interval of the Ridit value of both of them had no overlap with 3 or 4 region.So the treated curative effects of the patients from 1or 2 region were better than the others from 3 or 4 region(P>0.01).The therapeutic effect of 4 region was the worst, through comparing the 95% confidence interval of the Ridit value of the pationts whose protrusions located in 4 region with that in 3 region(table 5, figure 2-1).③Contrast the patients whose hemiated discs organism located in coronal surface with each others,we could get that The 95% confidence interval of the Ridit value of "a" region overlayed mostly with that of "b" region, their effects weren't significantly different with each other(P>0.05),and both of their clinical curative effects were better than "c" region.6.2 The relationship between CT imaging measure index and the effect of sacral canal injection on the patients with LDHAccording to the scatterplot chart, we could see that the improve index has linear correlation with the degree of the nerv-e root compresed, sagittal diameter index and the CT valu-e. The improve index was assumed to dependent variable "y",and the degree ofthe nerve root compresed, sagittal diameter index and the CT value was assumed to independent variable.We could get the result analysed by multivariate linear regression equation.Design stepwise regression equation:①Sagittal diameter index was remove d in the selected or eliminated process of regression equations variables(P=0.07 8).It showed that the clinical curative effect of caudal block anesthesia didn't r elate obviously with sagittal diameter index.;②The regression equation:Improv e index=1.264-0.567 degree of cauda equina compression-0.356 CT value.From the table, sagittal diameter index had an less effect on the clinical curative ef fect of sacral tube injection. Protrusions was more closer with the nerve root, the clinical symptoms the more serious,and then the effect of sacral tube inject ion become worse. If the CT value more bigger,the effect of sacral tube inject ion was more worse. Based on standardized regression coefficient,the degree of cauda equina compression was more closely related with the clinical effects,c ompared with CT value or sagittal diameter index.7 conclusionThe sacral canal injection's clinical effect is the best from the patients wh-ose CT showing that the Bulge, protrusion located in 1 region or a area,low density protrusion,less compression of nerve root and dural by protrusions.However,the patients aren't suitable for the treatment of caudal block anesthesia,whose CT showing sequestration,4 region(extremely lateral type),highdensity protrusion and serious compression of nerve root and dural by big protrusions.Although the CT scan is easy, good economic applicability, high diagnosis rate of prolapse of LDH, but in the actual operation process, we will encount er some situation such as the inaccurate measurement because of irregular shap e protrusions or part falling off. When making the synthetic discrimination in f act,we need combine with X-ray and MRI imaging method.On the whole, CT scan can provides imaging basis for clincal application of sacral canal injection of lumbar intervertebral disc.Through this experiment, we can regulate the clinical application of sacral tube injection and prognosis t he effect of sacral tube injection.